被叫作作“癌症之王”，非常多人发掘已然晚期……
<img src="https://mmbiz.qpic.cn/mmbiz_jpg/p1VfGFTkFsKA7TwVjnH5bORIAMKNNYYtic8jRQwt9K8eBTdSaKBopC6B7GT1Fhw6l76AA8KLb0mfkeNvONUqlAA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_gif/p1VfGFTkFsKA7TwVjnH5bORIAMKNNYYtxPa2jatP5mVDgumaWZUMpoN6aybR941my9n6usyiadvxWNeSdxufouQ/640?wx_fmt=gif&tp=webp&wxfrom=5&wx_lazy=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">癌症<span style="color: black;">做为</span>一类慢性<span style="color: black;">疾患</span>，给人类健康带来了<span style="color: black;">极重</span><span style="color: black;">困惑</span>。随着医学发展，许多癌症的诊断治疗都取得了进步，但癌症<span style="color: black;">行业</span>还是有众多亟待<span style="color: black;">解决</span>的难关。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsIlqUfzyVedyloW8UIP0e30G2iaG9Weoqaad9iavs8RBa8MicXsHTYZnXAibYFqbWwtcciaH97OcPvlWUg/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图｜新华社</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">在恶性肿瘤中，最难诊治的<span style="color: black;">疾患</span>之一当属胰腺癌。</strong></span>它起病隐匿，<span style="color: black;">初期</span>症状不典型，且<span style="color: black;">发展</span><span style="color: black;">快速</span>。待<span style="color: black;">病人</span><span style="color: black;">显现</span><span style="color: black;">明显</span>的临床表现就诊时，常常<span style="color: black;">已经是</span>晚期，手术、放化疗效果都不甚理想。因此，<span style="color: black;">公众</span><span style="color: black;">媒介</span>常将胰腺癌<span style="color: black;">叫作</span>为“癌症之王”，医学专家<span style="color: black;">亦</span>在行业共识中写到：“<span style="color: black;">做为</span>预后极差的消化系统肿瘤，胰腺癌的临床诊治极具挑战性。”</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">【注：预后<span style="color: black;">指的是</span>对病人<span style="color: black;">疾患</span>状态的发展、病情变化和治疗效果等<span style="color: black;">原因</span>进行判断和预测。】</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">对<span style="color: black;">非常多</span>人<span style="color: black;">来讲</span>，胰腺这个器官<span style="color: black;">好似</span>没什么存在感，连它<span style="color: black;">详细</span>在身体哪个位置都不<span style="color: black;">晓得</span>。<span style="color: black;"><strong style="color: blue;">但<span style="color: black;">便是</span>这个平日里一声不吭的器官，一出问题就很容易是大问题。</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">兵法有云，“知己知彼，百战不殆”。<span style="color: black;"><strong style="color: blue;"><span style="color: black;">为何</span>胰腺癌<span style="color: black;">初期</span>很难被<span style="color: black;">发掘</span>？在治疗上，经历了<span style="color: black;">那些</span>艰难的探索？高<span style="color: black;">危害</span>人群又有<span style="color: black;">那些</span>？</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">就让<span style="color: black;">咱们</span>穿越时光隧道，深入地<span style="color: black;">认识</span>一下胰腺癌这位可怕对手的前世今生吧。</p><span style="color: black;">文 |<span style="color: black;"> <span style="color: black;"><span style="color: black;">谷晓阳 </span></span><span style="color: black;">首都医科大学医学人文学院</span></span></span><span style="color: black;"><span style="color: black;"> <span style="color: black;">杜海琳</span><span style="color: black;"> 首都医科大学<span style="color: black;">附庸</span>安贞医院</span></span></span><span style="color: black;">编辑 | 王乙雯 瞭望智库</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">本文为瞭望智库原创<span style="color: black;">文案</span>，如需转载请在文前注明<span style="color: black;">源自</span>瞭望智库（zhczyj）及作者信息，否则将严格追究法律责任。</span></p><span style="color: black;"><strong style="color: blue;">1</strong></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">寻找“<span style="color: black;">隐匿</span>的器官”</span></span></strong></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">在一本<span style="color: black;">相关</span>胰腺历史的经典论著中，学者们<span style="color: black;">运用</span>了“<span style="color: black;">隐匿</span>的器官（hidden organ）”来描述胰腺。有此<span style="color: black;">叫作</span>谓，</span>很大程度上是<span style="color: black;">由于</span>在医学的历史上，<span style="color: black;"><span style="color: black;"><strong style="color: blue;">人们花了相当长的时间才拨开迷雾、<span style="color: black;">看清</span>胰腺的解剖位置和生理功能。</strong></span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">现代医学的历史根源<span style="color: black;">能够</span>追溯到古希腊，<span style="color: black;">因此呢</span><span style="color: black;">非常多</span>现代医学的名词<span style="color: black;">亦</span>都和古希腊文<span style="color: black;">相关</span>。胰腺这个脏器<span style="color: black;">亦</span>不例外，其英文Pancreas<span style="color: black;">源自</span>于希腊语<img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsJOD5BCK5K8FLh1IGsQ9pVlOclzqpEzZJiaBKVMsqibVbIr07FkZExu5VV49tVtnz6eibZYF5AZSxwbA/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">，由<span style="color: black;">暗示</span>all的前缀</span><img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsJOD5BCK5K8FLh1IGsQ9pVlYmskYR69lLFPrz5PWWgrmTNZd5BDwcSLKLKSGZPLM5qF4L3NjdLUaw/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">和<span style="color: black;">暗示</span>flesh的</span><img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsJOD5BCK5K8FLh1IGsQ9pVlqxHJ8IGkhfAaPFg0WP9bQRY47Ns6cpfBToxmQlZ75gYfa8Xp9QL1fg/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;"><span style="color: black;">形成</span>，字面意思为“全肉”。</span><span style="color: black;">胰腺的命名者可能是一位生活在公元1世纪的<span style="color: black;">大夫</span>拉弗斯（Rufus），他描述胰腺是“与肠道<span style="color: black;">初始</span>部并行的脂肪似的腺体状肉质”。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">胰腺<span style="color: black;">位置于</span>腹部靠后的位置，“藏”</strong></span><span style="color: black;"><strong style="color: blue;">在胃和肠道的后面，<span style="color: black;">周边</span>有许多神经、血管和消化导管。</strong></span>它看起来不像肝脏和脾脏那样血液丰富，功能<span style="color: black;">亦</span>不像心脏和肺脏那样和心跳<span style="color: black;">呼气</span>息息<span style="color: black;">关联</span>。在很长一段时间内，古代的医学家<span style="color: black;">始终</span>没能搞清楚胰腺的功能是什么，只能<span style="color: black;">按照</span>其位置和“外形”展开推测。<span style="color: black;">例如</span>，古罗马最著名的<span style="color: black;">大夫</span>盖伦（Claudius Galenus，129—199）就猜测：胰腺可能是个<span style="color: black;">拥有</span><span style="color: black;">守护</span>垫功能的器官。有<span style="color: black;">非常多</span>静脉、动脉和神经在胃之后汇合，这些管束都很脆弱，<span style="color: black;">因此呢</span>，这个区域<span style="color: black;">必定</span><span style="color: black;">必须</span>专门的<span style="color: black;">守护</span>。<span style="color: black;">因此</span>，大自然创造了胰腺，来填满这些管束<span style="color: black;">周边</span>的空隙，<span style="color: black;">这般</span>它们就不会撕裂、<span style="color: black;">亦</span>不会<span style="color: black;">没</span>物支撑了。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">在漫长的中世纪，盖伦被欧洲医学界奉为医学理论的绝对权威，他对胰腺功能的看法<span style="color: black;">亦</span>被代代传习。直到文艺复兴时期，盖伦的学术权威才受到比较<span style="color: black;">显著</span>的冲击。17世纪上半叶，解剖学的发展进一步推进了对胰的认识。1642年，帕多瓦大学的一位解剖技术员维尔松（Johann Georg Wirsüng，1589—1643）在公开解剖展示中<span style="color: black;">发掘</span>胰腺内存在导管（即胰管），它大约<span style="color: black;">位置于</span>胰腺中央，向<span style="color: black;">周边</span>延伸出许多分支。可惜，维尔松没搞清楚这根管道的功能是什么就去世了。<span style="color: black;">不外</span>，认识到胰管的存在之后，<span style="color: black;">火速</span>就有其他学者<span style="color: black;">发掘</span>其中有液体排出。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">17世纪，正是近代实验科学轰轰烈烈兴起的时代。学者们<span style="color: black;">亦</span><span style="color: black;">起始</span>设计实验探究胰腺所产生液体的生理功能。荷兰的<span style="color: black;">青年</span><span style="color: black;">大夫</span>德<span style="color: black;">·</span>格拉夫（Reignier de Graaf，1641—1673）开展动物实验，他把鹅的翮（即鹅羽毛中的硬管）<span style="color: black;">插进</span>胰管、收集胰液。类似的动物实验反反复复地进行着，在<span style="color: black;">专家</span>孜孜不倦的探索中，<span style="color: black;"><strong style="color: blue;">19世纪的生理学家<span style="color: black;">最终</span><span style="color: black;">知道</span>了胰液中含有消化酶，有消化<span style="color: black;">功效</span>，<span style="color: black;">因此呢</span>将之定义为消化器官。</strong></span>而不久之后的20世纪初，胰腺分泌胰岛素的外分泌功能<span style="color: black;">亦</span>随着内分泌学的发展被<span style="color: black;">知道</span>。</p><span style="color: black;"><strong style="color: blue;">2</strong></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">认识胰腺癌</span></span></strong></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">非常多</span>医史学家和医学家都认为，最早描述胰腺癌的是18世纪意大利著名解剖病理学家——莫干尼（Giovanni Battista Morgagni，1682—1771）。在18世纪之前，欧洲人<span style="color: black;">重点</span>用传统的四体液学说解释<span style="color: black;">疾患</span>的<span style="color: black;">原由</span>。这种学说自古希腊时期起<span style="color: black;">便是</span>医学的主流理论之一，其<span style="color: black;">重点</span>理念是：人<span style="color: black;">身体</span>有血液、黏液、黄胆汁和黑胆汁四种体液，它们的平衡和失衡影响着人体健康。而癌症，正是与黑胆汁<span style="color: black;">相关</span>，它淤积在人<span style="color: black;">身体</span><span style="color: black;">没</span>法排泄，就凝结<span style="color: black;">成为了</span>肿块。</p><img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsIlqUfzyVedyloW8UIP0e30ZM9Ov2jD1a3ujSiaUuFX1WYAotO6qHGYj1ibV0jE80npjxHkhDclQhzg/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">莫干尼（《由解剖观察诸病位置与<span style="color: black;">原由</span>》1761年版作者像）</span><span style="color: black;">图源：</span><span style="color: black;">Giovanni Bat</span><span style="color: black;">tista Morgagni. Line engraving by G. Volpato, 1761. Wellcome Collection. Public Domain.、</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">在莫干尼生活的年代，解剖学<span style="color: black;">已然</span>兴起。他<span style="color: black;">青年</span>时就崭露头角，<span style="color: black;">作为</span>帕多瓦大学的解剖教授。在任教的<span style="color: black;">同期</span>，他还在当地行医、担任医学顾问，这就使得他能够<span style="color: black;">认识</span><span style="color: black;">病人</span>的临床资料。<span style="color: black;">例如</span>，在<span style="color: black;">非常多</span><span style="color: black;">病人</span>生前，莫干尼知晓<span style="color: black;">她们</span>的症状、体征，而<span style="color: black;">病人</span>死后，他又能<span style="color: black;">经过</span>尸检观察<span style="color: black;">病人</span><span style="color: black;">身体</span>脏器的变化。在几十年的工作生涯中，莫干尼逐步认识到，<span style="color: black;"><strong style="color: blue;"><span style="color: black;">疾患</span>的<span style="color: black;">原由</span>不是体液的改变，而是和器官<span style="color: black;">相关</span>。<span style="color: black;">病人</span>外在表现出的症状，其根源应该是其<span style="color: black;">身体</span>器官<span style="color: black;">出现</span>了病变。</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1761年，79岁的莫干尼出版了《由解剖观察诸病位置与<span style="color: black;">原由</span>》（De Sedibus et Causis Morborum per Anatomem Indagatis）一书。在书中，他描述了<span style="color: black;">有些</span>胰腺<span style="color: black;">反常</span>的案例。<span style="color: black;">例如</span>，一位女士常年有呕吐<span style="color: black;">状况</span>。她死前留下遗言，<span style="color: black;">期盼</span>能有解剖学家搞清楚她的病因。<span style="color: black;">病人</span>死后，莫干尼和她的家庭<span style="color: black;">大夫</span><span style="color: black;">一块</span>参与了尸检，<span style="color: black;">发掘</span>她腹腔中有<span style="color: black;">海量</span>淡黄色的腹水，胆囊增大，胰腺很苍白。她的胰腺看起来<span style="color: black;">体积</span>正常，<span style="color: black;">然则</span>切开时却干燥而僵硬，和正常胰腺的质感不同。莫干尼推测胰腺的肿物和<span style="color: black;">病人</span>死亡<span style="color: black;">相关</span>。在接下来，他又提起一个自己50年前听闻的病例，<span style="color: black;">病人</span><span style="color: black;">亦</span>是有<span style="color: black;">长时间</span>呕吐，死亡后解剖<span style="color: black;">发掘</span>胰腺肿大、布满了不规则的肿块，硬度就像软骨那样。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">莫干尼记录的胰腺肿瘤虽不太多，却敏锐地察觉到了这种<span style="color: black;">疾患</span>非常难于<span style="color: black;">发掘</span></strong></span><span style="color: black;"><strong style="color: blue;">。</strong></span>他指出：胰腺位置隐蔽，与体表隔着较多器官，如：含气的胃以及肝脏（<span style="color: black;">倘若</span><span style="color: black;">病人</span>的肝脏增大就愈发干扰诊断）。<span style="color: black;">因此</span>，除非<span style="color: black;">病人</span>胰腺肿瘤的体积很大或是<span style="color: black;">病人</span>非常瘦削憔悴，否则<span style="color: black;">大夫</span>很难<span style="color: black;">经过</span><span style="color: black;">检测</span><span style="color: black;">病人</span>的身体，观察或触摸到肿物。面对这些困难，<span style="color: black;">大夫</span>只能依靠其他迹象做出诊断。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">在<span style="color: black;">这般</span>的困境中，<span style="color: black;">大夫</span>们<span style="color: black;">独一</span>的诊断<span style="color: black;">办法</span><span style="color: black;">便是</span>依赖临床观察。</strong></span>18世纪到19世纪，比格斯比（John Jeremiah Bigsby，1792—1881)、布莱特（Richard Bright，1789—1858）等胰腺<span style="color: black;">疾患</span>先驱逐步<span style="color: black;">发掘</span>了胰腺癌较为典型的临床表现，<span style="color: black;"><strong style="color: blue;"><span style="color: black;">包含</span>腹痛、腹泻、黄疸、消瘦、乏力等。</strong></span>尤其是，不止一位<span style="color: black;">大夫</span>观察到<span style="color: black;">病人</span>的腹痛有着<span style="color: black;">显著</span>的特点：如<span style="color: black;">摄食</span><span style="color: black;">导致</span>的胃胀，或便秘<span style="color: black;">导致</span>的腹胀，<span style="color: black;">一般</span>会使腹痛加重；直立姿势<span style="color: black;">亦</span>会加重<span style="color: black;">病痛</span>，而弯曲身体时能够减轻。<span style="color: black;">病痛</span><span style="color: black;">能够</span>放射到胸部和背部，<span style="color: black;">夜晚</span>比<span style="color: black;">白日</span>更严重。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">可是，<span style="color: black;">没</span></strong></span><span style="color: black;"><strong style="color: blue;">论<span style="color: black;">大夫</span>做出多少细致观察，都很难改变一个事实：<span style="color: black;">大夫</span>能给予<span style="color: black;">病人</span>的<span style="color: black;">帮忙</span>微乎其微。</strong></span>在众多关于胰腺癌的<span style="color: black;">初期</span>记录中，充斥着<span style="color: black;">病人</span>的痛苦症状和<span style="color: black;">大夫</span><span style="color: black;">白费</span>的尝试。<span style="color: black;">吃下</span>鸦片、放血、灌肠……虽然<span style="color: black;">大夫</span>在竭尽所能，用当时能想到的一切办法缓解<span style="color: black;">病人</span>的症状、减少其痛苦，但都很难更改<span style="color: black;">病人</span><span style="color: black;">最后</span>死亡的<span style="color: black;">结果</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">另外</span>，<span style="color: black;">必须</span>强调的是，<span style="color: black;">咱们</span><span style="color: black;">无</span>办法确定莫干尼<span style="color: black;">或</span><span style="color: black;">以上</span>其他<span style="color: black;">大夫</span>所描述的胰腺<span style="color: black;">疾患</span>到底<span style="color: black;">是否</span>胰腺癌。这和<span style="color: black;">咱们</span>对癌症的认识变化<span style="color: black;">相关</span>：<span style="color: black;">咱们</span>如今的癌症诊断，都是依托于显微镜下的组织病理<span style="color: black;">检测</span>所做出的，癌细胞会表现出细胞结构<span style="color: black;">错乱</span>、细胞间粘着性降低、<span style="color: black;">控制</span>现象丧失等特点。而在莫干尼生活的时代，显微镜还远<span style="color: black;">无</span>如此<span style="color: black;">精细</span>，<span style="color: black;">大夫</span><span style="color: black;">亦</span>还<span style="color: black;">无</span>癌细胞的概念。有史可查的最早在显微镜下诊断胰腺癌的人可能是美国<span style="color: black;">大夫</span>科斯塔（Jacob Mendez Da Costa，1833—1900）。1858年，他<span style="color: black;">报告</span>了37例病例，这其中就<span style="color: black;">包含</span>了文献中可查证的最早的<span style="color: black;">经过</span>显微镜确诊的胰腺癌。</p><span style="color: black;"><strong style="color: blue;">3</strong></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;"><span style="color: black;">繁杂</span>且危险的治疗探索</span></span></strong></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">时<span style="color: black;">迄今</span>日，胰腺癌最<span style="color: black;">重点</span>的治疗<span style="color: black;">办法</span>是外科手术。</strong></span>在历史上，<span style="color: black;">非常多</span>外科<span style="color: black;">大夫</span>曾经想到过剖开<span style="color: black;">病人</span>身体，切除掉那个让<span style="color: black;">病人</span>不适的肿块，<span style="color: black;">然则</span>“感染”“<span style="color: black;">流血</span>”“缺少<span style="color: black;">麻木</span>”等困境限制着外科手术的开展。直到19世纪，随着<span style="color: black;">麻木</span>术的应用、细菌学说的传播、<span style="color: black;">没</span>菌术的确立，外科手术克服了“<span style="color: black;">病痛</span>”“感染”两大阻碍，得到<span style="color: black;">明显</span>的发展，<span style="color: black;">有些</span>外科<span style="color: black;">大夫</span><span style="color: black;">亦</span><span style="color: black;">起始</span>尝试完成腹腔大手术。<span style="color: black;">然则</span>，<span style="color: black;"><strong style="color: blue;"><span style="color: black;">因为</span>胰腺<span style="color: black;">位置于</span>人体左上腹最深处，与肝、胆、肠、胃等器官紧密相邻，<span style="color: black;">周边</span>有错综<span style="color: black;">繁杂</span>的血管和神经组织。<span style="color: black;">因此</span>，胰腺癌的外科手术治疗面临着比<span style="color: black;">通常</span>手术更为<span style="color: black;">繁杂</span>的<span style="color: black;">状况</span>。</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">在胰腺癌外科治疗中，最早<span style="color: black;">显现</span>的是胆肠吻合术，如今医学界将之<span style="color: black;">叫作</span>为姑息治疗。</strong></span>这种手术<span style="color: black;">没</span>法切除肿瘤，只能在<span style="color: black;">必定</span>程度上缓解<span style="color: black;">病人</span>的症状，改善其<span style="color: black;">存活</span>质量。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">胰腺癌<span style="color: black;">病人</span>大多会<span style="color: black;">显现</span>黄疸症状。其<span style="color: black;">原由</span>是肿瘤压迫肝外胆管，阻碍胆汁的正常流通。胆汁<span style="color: black;">因此呢</span>逆流入血，<span style="color: black;">诱发</span><span style="color: black;">病人</span>巩膜及全身皮肤黏膜黄染、尿液发黄、大便呈陶土色、皮肤瘙痒等症状，严重时会<span style="color: black;">导致</span>凝血功能<span style="color: black;">阻碍</span>。而胆肠吻合术<span style="color: black;">便是</span>将阻塞部位近侧的胆管和肠管直接接起来，使胆汁能经过这个接口流到肠内。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">历史上<span style="color: black;">第1</span>例胰腺癌姑息手术是<span style="color: black;">大夫</span>“<span style="color: black;">没</span>意间”完成的。1882 年，比利时外科<span style="color: black;">大夫</span>温尼瓦特 (Alexander von Winiwarter，1848—1917)接诊了一名<span style="color: black;">身患</span>严重阻塞性黄疸的女性<span style="color: black;">病人</span>，他将<span style="color: black;">病人</span>的胆囊和空肠吻合，<span style="color: black;">处理</span>了她的不适症状，<span style="color: black;">同期</span><span style="color: black;">亦</span>进行了医学史上首例姑息性治疗胰腺癌手术。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsIlqUfzyVedyloW8UIP0e30JPnVWvGXPPgawxk68n5lWnAls3U5MHQltVuklMZj7o3PV1JzBUBQ2Q/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">胰腺解剖位置示意图。<span style="color: black;">源自</span>：百度百科</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">另一个治疗方式是部分切除。</strong></span>从胰腺的解剖图中<span style="color: black;">咱们</span><span style="color: black;">能够</span>看出，相较于它的头部，胰尾的解剖结构更为简单，这使得胰尾部肿瘤切除术<span style="color: black;">作为</span><span style="color: black;">大夫</span>最早的胰腺切除术探索。<span style="color: black;">第1</span>例胰腺癌切除术<span style="color: black;">出现</span>在1882年7月，德国外科<span style="color: black;">大夫</span>弗里德里希·特兰德伦堡（Friederich Trendelenburg，1844—1924）为一位长有腹部巨大肿瘤的女性开展手术，<span style="color: black;">必须</span>切除胰尾。<span style="color: black;">因为</span>胰尾紧邻脾脏，受技术<span style="color: black;">前提</span>限制，<span style="color: black;">大夫</span>在术中<span style="color: black;">损害</span>了<span style="color: black;">病人</span>的脾脏，不得不将脾一同切除。术后，<span style="color: black;">病人</span><span style="color: black;">显现</span>了严重的伤<span style="color: black;">口味</span>染和进行性营养不良，于<span style="color: black;">几周</span>后去世。这个惨痛的案例标志着胰腺癌手术治疗跌跌撞撞的<span style="color: black;">起始</span>，呼应着它艰难跋涉的过去，<span style="color: black;">亦</span>预示着它充满挑战的<span style="color: black;">将来</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">19世纪末20世纪初，大<span style="color: black;">都数</span>外科<span style="color: black;">大夫</span>都认为对胰腺进行手术是极为困难和危险的。</strong></span><span style="color: black;">因为</span>缺乏有效的止血技术，<span style="color: black;">没</span>论是切开胰腺摘除肿瘤或切除胰腺组织部分都可能使<span style="color: black;">病人</span>失血<span style="color: black;">太多</span>而死。<span style="color: black;">况且</span>，<span style="color: black;">因为</span>胰腺与胃及十二指肠关系密切，若想完全切除胰头部，就<span style="color: black;">必须</span>切除胰十二指肠动脉及胃网膜右动脉；而这两条动脉分别为十二指肠和胃组织供血，器官缺少了血供就会<span style="color: black;">引起</span>坏死，<span style="color: black;">因此</span>在切除胰头时<span style="color: black;">通常</span><span style="color: black;">必须</span>把十二指肠一并切除，有时还要切除一部分的胃。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">如此大规模的腹腔手术令人望而却步。1898年，医学史上首例胰十二指肠切除术的<span style="color: black;">病人</span>在术后21天死于多种术后并发症。<span style="color: black;"><strong style="color: blue;">直至20 世纪 30 年代，医学史上仅有3名<span style="color: black;">病人</span>成功熬过了胰十二指肠切除术。</strong></span>胰腺外科极负盛名的外科<span style="color: black;">大夫</span>惠普尔（Allen Oldfather Whipple，1881—1963）忍不住在日记中写道，“切除胰腺癌……这类手术成为了一种危险操作，即使是水平很高的外科<span style="color: black;">大夫</span><span style="color: black;">亦</span>不敢轻易尝试。”</p><img src="https://mmbiz.qpic.cn/mmbiz_png/p1VfGFTkFsIlqUfzyVedyloW8UIP0e30g8fW5A82nBPlbFUb6Q0fGF7txmr9pibBqgbNE3vwqia6ia3R2Ke1A9AaQ/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">惠普尔<span style="color: black;">大夫</span> </span><span style="color: black;">图源：Schnelldorfer T, Adams DB, Warshaw AL, Lillemoe KD, Sarr MG. Forgotten pioneers of pancreatic surgery: beyond the favorite few. Ann Surg. 2008 Jan;247(1):191-202.</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">惠普尔在前人的<span style="color: black;">基本</span>上总结手术经验，又加入了自己在手术实践中的思考。1935年，惠普尔在美国外科协会会议上<span style="color: black;">报告</span>了3名分两<span style="color: black;">周期</span>进行胰十二指肠切除</span><span style="color: black;">术的</span><span style="color: black;">病例，</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">他指出，胰腺手术之<span style="color: black;">因此</span>如此难以成功完成，<span style="color: black;">重点</span>是<span style="color: black;">由于</span>存在两个误区：</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">第1</span>，外科<span style="color: black;">大夫</span>们认为胰液的正常分泌对人体<span style="color: black;">来讲</span>必不可少。</span></strong></span><span style="color: black;">因此呢</span><span style="color: black;">大夫</span>们在完成胰十二指肠的切除，并重新缝合肠道后，执着于向剩余的肠腔内<span style="color: black;">移植</span>胰管，试图恢复胰液的分泌。但这就<span style="color: black;">引起</span>了<span style="color: black;">拥有</span>消化<span style="color: black;">功效</span>的胰液在肠管内激活，使手术“组合”好的肠管<span style="color: black;">显现</span>炎症、狭窄等<span style="color: black;">状况</span>，从而<span style="color: black;">引起</span>手术失败；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">第二，外科<span style="color: black;">大夫</span>们尝试一次性切除胰腺肿瘤。</span></strong></span><span style="color: black;">因为</span><span style="color: black;">身患</span>胰腺癌的<span style="color: black;">病人</span>常常<span style="color: black;">伴同</span>着严重的梗阻性黄疸且身体虚弱、营养不良，这就<span style="color: black;">引起</span><span style="color: black;">病人</span>很难熬过这类大型手术。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">因此</span>，惠普尔提出了分期手术，即<span style="color: black;">第1</span><span style="color: black;">周期</span>先将胆汁引流入肠道，恢复胆汁循环，缓解<span style="color: black;">病人</span>症状；第二<span style="color: black;">周期</span>再进行切除术。</span></strong></span>他的这份报告得到当时外科界的广泛认可，标志着胰腺外科<span style="color: black;">行业</span>的重大进步，向外科<span style="color: black;">大夫</span>们证明胰腺<span style="color: black;">能够</span>以相对安全的方式进行手术。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">20世纪30年代末，多项医学<span style="color: black;">科研</span>的进步<span style="color: black;">亦</span>给胰腺手术的安全实施<span style="color: black;">供给</span>了<span style="color: black;">保证</span>。其中的典型<span style="color: black;">表率</span><span style="color: black;">便是</span>维生素K的<span style="color: black;">发掘</span>、分离和合成。胰腺癌的<span style="color: black;">病人</span>大部分都是胰头癌，胰头肿物压迫肝外胆管<span style="color: black;">引起</span>胆汁入血，继而<span style="color: black;">诱发</span>凝血<span style="color: black;">阻碍</span>，这为术中止血及<span style="color: black;">病人</span>术后恢复造<span style="color: black;">成为了</span>很大困难。但维生素K与胆汁中的胆盐结合后，能够有效地逆转因<span style="color: black;">长期</span>胆道梗阻所<span style="color: black;">导致</span>的凝血功能<span style="color: black;">阻碍</span>。<span style="color: black;">另外</span>，人体血型的<span style="color: black;">发掘</span>和<span style="color: black;">科研</span>，<span style="color: black;">亦</span>使得输血技术取得<span style="color: black;">显著</span>进步。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">在这些<span style="color: black;">科研</span>的<span style="color: black;">基本</span>上，惠普尔改进了胰十二指肠切除术，带来了胰腺外科<span style="color: black;">行业</span><span style="color: black;">拥有</span>划时代<span style="color: black;">道理</span>的<span style="color: black;">发展</span>。</span></strong></span>1940年3月6日，惠普尔对一位被诊断为胃癌及胰腺癌的<span style="color: black;">病人</span>进行了首次一次性的胰十二指肠切除术，<span style="color: black;">病人</span>术后恢复顺利。在随后<span style="color: black;">发布</span>的病例报告中，惠普尔指出，分两次手术会<span style="color: black;">导致</span>腹腔脏器粘连，相比较之下，有了维生素K等<span style="color: black;">发掘</span>的<span style="color: black;">帮忙</span>，一次性的手术更值得提倡。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">由此，一次性的胰十二指肠切除术<span style="color: black;">作为</span>了大<span style="color: black;">都数</span>胰腺癌<span style="color: black;">病人</span>的首选。尽管惠普尔在1940年施行的手术操作并非独特，且<span style="color: black;">表率</span>了<span style="color: black;">数年</span>来<span style="color: black;">累积</span>的知识和经验，但它很快就<span style="color: black;">作为</span>了技术标准。1940年后，胰十二指肠切除术得到更广泛的接受。此后，外科<span style="color: black;">行业</span>的专家们继续在惠普尔所推行的胰十二指肠切除术的<span style="color: black;">基本</span>上进行细化和改进。<span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">日前</span>，胰十二指肠切除术仍是<span style="color: black;">初期</span>胰头癌的首选治疗<span style="color: black;">办法</span>。</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">日前</span>，胰腺癌的治疗<span style="color: black;">重点</span><span style="color: black;">包含</span>手术治疗、放射治疗、化学治疗和支持治疗等</span></strong></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">。外科手术切除术仍是胰腺癌<span style="color: black;">病人</span>获得治愈机会和<span style="color: black;">长时间</span><span style="color: black;">存活</span>的<span style="color: black;">独一</span>有效<span style="color: black;">办法</span>。</span></strong></span>然而，超过80%的胰腺癌<span style="color: black;">病人</span>因<span style="color: black;">发掘</span>时<span style="color: black;">已经是</span>晚期而失去手术机会。<span style="color: black;">另外</span>，放射治疗<span style="color: black;">亦</span>是胰腺癌的<span style="color: black;">要紧</span>治疗手段，贯穿于胰腺癌的各个分期。<span style="color: black;">针对</span>部分晚期胰腺癌<span style="color: black;">病人</span>，放化疗是首选治疗手段。</p><span style="color: black;"><strong style="color: blue;">4</strong></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;"><span style="color: black;">咱们</span>能做些什么</span></span></strong></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">胰腺癌是种恶性程度极高的消化系统肿瘤。据全国肿瘤登记中心统计，<span style="color: black;">截止</span>2021年，胰腺癌占我国肿瘤<span style="color: black;">出现</span>率的第９位，占死亡率的第６位，<span style="color: black;"><strong style="color: blue;"><span style="color: black;">其<span style="color: black;">重点</span><span style="color: black;">原由</span>在于<span style="color: black;">初期</span>诊断困难。</span></strong></span><span style="color: black;">非常多</span>人<span style="color: black;">显现</span>症状时就<span style="color: black;">已经是</span>肿瘤晚期，<span style="color: black;">此时</span>候能做的治疗<span style="color: black;">亦</span>屈指可数。幸而，有<span style="color: black;">科研</span>指出，从胰腺发<span style="color: black;">患病</span>变<span style="color: black;">起始</span>到发展为转移性胰腺癌<span style="color: black;">必须</span>近21年的时间，这为胰腺癌的<span style="color: black;">初期</span>筛查<span style="color: black;">供给</span>了足够的时间。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">那<span style="color: black;">是否</span>所有人都<span style="color: black;">必须</span>进行<span style="color: black;">初期</span>筛查呢？<span style="color: black;">按照</span>2022年年初<span style="color: black;">颁布</span>的《中国胰腺癌高危人群<span style="color: black;">初期</span>筛查和监测共识意见（2021）》，不<span style="color: black;">举荐</span>对<span style="color: black;">没</span>症状非高<span style="color: black;">危害</span>人群进行胰腺癌筛查。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">那样</span>，什么是高<span style="color: black;">危害</span>人群呢？</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">高<span style="color: black;">危害</span>人群<span style="color: black;">包含</span>四类：</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">1. 遗传性胰腺癌高危个体</span></strong></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">：</span></strong></span>指<span style="color: black;">拥有</span>胰腺癌家族史或已证实携带胰腺癌易感基因的个体。若有两个互为的一级亲属家庭成员确诊胰腺癌，<span style="color: black;">例如</span>一个家庭中的爸爸和奶奶都是胰腺癌<span style="color: black;">病人</span>，<span style="color: black;">那样</span>家里的儿子则<span style="color: black;">思虑</span>存在胰腺癌家族史；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">2. 新发糖尿病：</span></strong></span>既往<span style="color: black;">无</span>糖尿病、一年内诊断的糖尿病。专家共识<span style="color: black;">举荐</span>50岁以上且体质量指数（BMI）低和/或不明<span style="color: black;">原由</span>体重减轻以及短期内血糖波动<span style="color: black;">很强</span>的新发糖尿病<span style="color: black;">病人</span>尽早进行胰腺癌的<span style="color: black;">初期</span>筛查；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">3. 慢性胰腺炎<span style="color: black;">病人</span>；</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">4. 胰腺囊性肿瘤的<span style="color: black;">病人</span>。</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">尽管历经了数个世纪的探索，胰腺癌的诊断和治疗<span style="color: black;">情况</span>仍谈不上<span style="color: black;">阳光</span>。在医学界<span style="color: black;">持续</span>探索的<span style="color: black;">同期</span>，大至社会、小至个人，都应该关注、<span style="color: black;">注意</span>这种<span style="color: black;">疾患</span>，<span style="color: black;">尽可能</span>推动胰腺癌的<span style="color: black;">初期</span><span style="color: black;">发掘</span>和<span style="color: black;">初期</span>治疗。</p><span style="color: black;">参考文献：</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">沈珊珊,李洪祯,余媛媛.中国胰腺癌高危人群<span style="color: black;">初期</span>筛查和监测共识意见(2021,南京).临床肝胆病杂志,2022,38(05):1016-1022.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">Von Mikulicz-Radecki. I. Surgery of the Pancreas With Especial Consideration of Trauma and Inflammatory Processes［J］. Ann Surg. 1903 Jul;38(1):1-29.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">Carolyn J. Gersh. Naming the Body: A Translation with Commentary and Interpretive Essays of Three Anatomical Works Attributed to Rufus of Ephesus. Michigan:University of Michigan,2012.</span></p><span style="color: black;">Galen. C. G. Kühn ed, Opera Omnia (Complete works), Vol.Il. Leipzig: </span><span style="color: black;">Cno</span><span style="color: black;">b</span><span style="color: black;">loch,1821.</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">John M. Howard, Walter Hess. History of the Pancreas:Mysteries of a</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">Hidden Organ.New York: Springer </span><span style="color: black;">Science+Business Media, LLC,2002:6，17-19, 47-72.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">J. Da Costa. On the Morbid Anatomy and Symptoms of Cancer of the Pancreas. JB Lippincott & Company, Philadelphia，PA,USA(1858).</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">赵玉沛，郑雷.胰腺癌.长沙:中南大学出版社，2019.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">Schnelldorfer T, Adams DB, Warshaw AL, Lillemoe KD, Sarr MG. Forgotten pioneers of pancreatic surgery: beyond the favorite few［J］. Ann Surg.2008</span><span style="color: black;">Jan;247(1):191-202.</span></p><span style="color: black;">国家卫生健康委办公厅. 胰腺癌诊疗指南 (2022 年版). 临床肝胆病杂志, 2022, 38(5):10.</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><strong style="color: blue;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;">库叔福利</strong></span></strong></strong></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">库叔的赠书活动<span style="color: black;">始终</span>都在！<span style="color: black;"><span style="color: black;"><strong style="color: blue;">当代世界出版社</strong></span></span>为库叔<span style="color: black;">供给</span>10本<span style="color: black;"><strong style="color: blue;">《坚韧的中国：1840年<span style="color: black;">败兴</span>的回顾与展望》</strong></span>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">赠予<span style="color: black;">热情</span>读者。以史观今、以今问史，<span style="color: black;">统一</span>经济运行、政治运作、文明演进等核心要素，深刻揭示中华民族开放<span style="color: black;">包涵</span>、坚韧不拔的民族气质和发展内核。请<span style="color: black;">大众</span>在<span style="color: black;">文案</span>下评论，点赞最高的前2名（数量超过30）将得到赠书。</p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></p>
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